Variables e instrumentos para evaluar la salud mental en nadadores de competición: una revisión narrativa

Background Mental health issues are becoming increasingly prevalent among elite athletes, and during the Tokyo 2020 Olympic Games, this issue became a pressing concern. In particular, several athletes complained about their mental health in relation to the highly demanding demands of their sport. High-performance swimming exposes athletes to a variety of stressors due to the physical, technical and mental demands of the sport. The study has carried out a narrative review of the main variables related to mental health, their dimensions and evaluations in competitive swimmers. Methods Clearly planned and ordered potential studies were identified using combined search methods. The search was carried out in different bibliographic databases (Dialnet, Web of Science and Scopus) between 1990 and 2023. Google Scholar was used to manually search the reference lists of the retrieved studies to identify potentially eligible studies that were not included in the electronic searches. The studies were examined from three different perspectives. Firstly, the methodology, sample, swimming categories and their relationship with mental health were analysed. Secondly, the variables related to mental health symptoms and disorders. Finally, the main mental health analysis tools and the conclusions of the studies. Results The concept of mental health in competitive swimmers needs to be clarified in the scientific literature, as different variables have been analysed and multiple instruments have been used with small samples of swimmers, without any intervention and prevention protocol. In addition, the bodies and institutions involved should work in an interdisciplinary and collaborative manner, establishing specific programmes to ensure effective prevention and care. Conclusions Studies are needed to fill this gap and it is necessary to work under the same consensus and in collaboration with specified technical teams. In order to monitor, evaluate and provide services through detection tests and support to swimmers in their training and competitions.


Introduction
Mental health problems are increasingly present among elite athletes and it was during the Tokyo 2020 Olympics when it was an urgent call for this issue.In particular, several athletes complained about their mental health situation regarding the highly demanding inquiries about their sports modalities.Moreover, the World Health Organization (WHO) defines "global health" as "a state of complete physical, mental, and social well-being,".This definition explicitly stresses that mental health is vital to our ability to think, feel and interact among us (Jackson et al., 2022;World Health Organization, 2018).However, far from this definition in terms of health, in high-competition swimming, the athletes are exposed to different stressors in high competition due to the physical, technical and mental demands (Hooper et al., 2022;Salazar et al., 1997;Trinidad et al., 2021).Likewise, it was also corroborated that psychological preparation and sports psychologists are essential factors within the technical teams with a view to the optimal performance of swimmers (Rice et al., 2016).It was not until 2017 that the International Olympic Committee (IOC) began to take care of the mental health of athletes, creating a specific working group (MHWG), to develop an evaluation and early recognition tool on the possible risks of suffering from mental health symptoms and disorders (Gouttebarge et al., 2021).
Since the 1990s, the scientific literature has emphasised mental health's role among competitive swimmers.This factor is as important as physical health in optimising the athlete's performance and well-being.However, this concept has been unnoticed by sports coaches and psychologists, due to the limited literature on swimming and the benefits of this sport for mental health (Geamonond, 2018).The scarcity of research that has had competitive swimmers as an object of study has been a visible fact (Jackson et al., 2022;Rice et al., 2016).Even in a recent review study (Gouttebarge et al., 2019), the absence of these athletes is evidenced by not characterizing them specifically (Hughes & Leavey, 2012;Reardon & Factor, 2010).Similarly, high-quality systematic studies and intervention trials have been limited (Rice et al., 2016;Gouttebarge et al., 2021), as well as descriptive research on the extent of mental health symptoms and disorders (Gouttebarge et al., 2019).This evidence set off alarms among swimmers, coaches and technical teams, as high rates of highly prevalent mental disorders begin to appear (Rice et al., 2016).This is contrary to the statement that swimming causes the sensation of well-being and relaxation, as well as control of anxiety, stress and fatigue (Cordeiro et al., 2017).Some factors include intense physical activity, overtraining, injuries and exhaustion (Peluso & Andrade, 2005), proximity to sports retirement (Gouttebarge et al., 2016), a strict diet (Sundgot- Borgen & Torstveit, 2004), physical and competitive stress, along with pressure from the public, the media, and the social media (Bruner et al., 2008;Fletcher & Wagstaff, 2009;Hanton et al., 2005;Noblet & Gifford, 2002).Moreover, it should be added that athletes do not seek help for reasons such as a bad reputation, lack of understanding, the impact on performance and the perception that seeking help is a weakness (Reardon & Factor, 2010;Gulliver et al., 2012).This generates a high risk of mental illness that reduce sporting success (Rice et al., 2016).
Therefore, something must be fixed since the literature has warned us of the importance of psychological preparation and mental training (Nideffer, 1985;Ryan, 1982).Moreover, putting up with the high training loads does not only depends on physical, technical and tactical preparation in order to achieve high performance (Salazar et al., 1997).Subsequently, the novelty of this study is to review the different works that examine the mental health of swimmers and the tools displayed to examine those characteristics of mental health in this population.To date, it seems that no previous review has examined the different tools and measures to portray competitive swimmers' mental health situation.Therefore, this study aimed to carry out an analysis of the scientific tests taken with mental health in the discipline of swimming, as well as to examine the type of instrument used to evaluate and diagnose this situation in highly competitive swimmers.

Study design
A narrative review or literature review was carried out where the materials published in the literature (tests and instruments to evaluate and diagnose mental health in highly competitive swimmers) were described, in order to perform a textual, tabular or graphic synthesis of your results.and contributions (Grant & Booth, 2009).
The start of the study was in February 2023 through combined search processes, in which potential studies, clearly planned and ordered, were identified.In orden to perform that, the following bibliographical databases were consulted: Dialnet, WOS (Web of Science) and Scopus with the following search terms included in Boolean search strategies: REVISED Amendments from Version 2 The keywords have been updated to English.
Any further responses from the reviewers can be found at the end of the article

Data collection
By using filter criteria of the respective databases, the search was limited to publication dates (from 1 January 1990 to 30 June 2023), species (humans), and English and Spanish languages.Moreover, Google Scholar was used for the search and a manual search of the reference lists of the retrieved studies was performed to identify potentially eligible studies that were not captured by the electronic searches.
To avoid internal biases in studies and between studies, the following criteria were adopted: -Articles published from 1990 to 2023.
-Full-text articles written in English or Spanish languages (to reduce the bias of the revised publication) and peerreviewed (to guarantee a minimum of manuscript quality and a minimum of reliability).
-Articles that analyzed competitive swimmers based on scientific methodology, with one or more measuring instruments in different variables.
Those that did not meet these criteria were excluded, as were books, book chapters, theses, thesis reviews, case study presentations, conference notes, and studies focused on non-competitive, amateur or triathlon swimmers.Also, it is important to note that research were only taken after extensively searching for existing research in that field.

Data analysis
For collection and data organization, the tools offered by the different databases were used (text availability, article attributes, article type, publication date…).The data analysis was considered from three different points of view.Firstly, the methodology, sample, swimming categories (swimmers who competed in regional, university, national, international, masters championships and who had a minimum of 2 hours of training per week) were analysed and their relationship with mental health in competitive swimmers.Secondly, those variables (anxiety; motivation; self-esteem; goal orientation and goal setting; intensity and level of performance; importance of the test; coping; eating and depressive disorders; stress and recovery; exhaustion; tension, optimism and pessimism) that were related to mental health symptoms and disorders in competitive swimmers.Finally, the main analysis instruments for the mental health of competitive swimmers.
Table 1 shows the main research, as well as the methodology used, the sample and the swimming category of the analysed swimmers.Particularly, most studies followed a cross-sectional design (n = 8), followed by longitudinal (n = 4), comparative (n = 5) and a review (n = 1).Moreover, the sample was made up of 1174 swimmers.On the other hand, the swimming categories were: elite (n = 7), national/international (n = 3), master (n = 1), national (n = 1), university/ international (n = 1), international (n = 1) and regional/national (n = 1).The period in which the studies were published was in a range of 27 years (from 1994 until June 2023).

Results
Searches were made using titles, abstracts and keywords.The first comprehensive search yielded a total of 512 records.
One additional article was identified by other means.After removing duplicates, 72 documents were identified, of which 41 were excluded as they were not directly related to the objective of the study.Finally, 59 articles were reviewed and, after applying the inclusion criteria, the 18 articles included in this review were selected (Figure 1).
Variables examined in previous works related to mental health in swimmers Table 2 shows the main variables that examined the symptoms and disorders of mental health in competitive swimmers.
The main studies focused on analyzing different variables such as: performance anxiety, as well as before and after competition; individual and group motivation; the self-esteem; orientation and goal setting; intensity and level of performance; the importance of the test; coping; eating and depressive disorders; stress and recovery; exhaustion, as well as tension, optimism and pessimism.
Table 2. Variables analysed about symptoms and mental health disorders in competitive swimmers.

Causes of mental disorders in swimmers
Table 4 shows how the studies affirm that the high levels of physical activity that elite swimmers develop may cause highstress levels, depression and anxiety, even after the competition cancellation, which psychological distress symptoms The findings suggest that elite performers do not differ from non-elite performers on the intensity of pre-competition anxiety symptoms, but that they do have a more positive interpretation of these symptoms in terms of their consequences for performance.They also suggest that elite performers who do experience debilitative anxiety symptoms possess an effective cognitive strategy for maintaining confidence levels.
Jones & Hanton (1996) The investigation has generated interesting findings that serve to understand further the relationship between goal attainment expectancies and debilitative and facilitative competitive anxiety.The findings also have practical implications for achieving appropriate preperformance states via goal-setting strategies.They emphasize, in particular, the importance of setting goals perceived as attainable and within the performer's control.Salazar et al. (1997) Psychological preparation is a fundamental element for optimal performance in elite athletes.
Hanton & Jones (1999) The findings indicate that elite athletes experience and recall more demands associated primarily and directly with the sports organization than with competitive performance.Furthermore, this population appears more likely to mention similar competitive stressors but varied organizational stressors, probably because the former are inherent and endemic to elite sports, whereas the latter are essentially extraneous and widely distributed.

Byrne & McLean (2002)
The results suggest that athletes have a higher prevalence of eating disorders than non-athletes.However, it is not so much being an athlete that places an individual at increased risk for developing an eating disorder.Instead, athletes competing in sports that emphasise the importance of a thin body shape or a low body weight appear particularly vulnerable.

Hatzigeorgiadis & Chroni (2007)
The results suggest that facilitative perceptions of anxiety symptoms relate to more adaptive cognitive and behavioural outcomes.Coaches should therefore emphasize not only the regulation of anxiety intensity, but also the way swimmers perceive anxiety symptoms.

Abrahamsen et al. (2008)
The extant motivational climate affects performance anxiety, and coaches should consider this when working with elite national athletes.

Torstveit et al. (2008)
A higher prevalence of eating disorders was found among athletes competing in leanness sports compared with both athletes competing in non-leanness sports and controls.Therefore, we need to emphasize what kind of athletes we address when we talk about a higher prevalence of eating disorders in the sports environment.Using a risk criteria model including questions about menstrual dysfunction may be valuable in detecting Eating disorders in leanness sport athletes.However, it is sufficient to utilise self-report measures in non-leanness athletes.

Romberg et al. (2012)
Despite the increased asthma prevalence among the swimmers, they reported a high degree of mental and physical well-being, indicating that the sports environment per se compensated for eventual health drawbacks.Moreover, being active on the recreational level promotes a healthier lifestyle, an enhanced sense of well-being and fewer psychosomatic symptoms.

Simões et al. (2012)
Goal setting can be considered an overall context in which mental training can be integrated.It is more important for sport psychology to define the best psychological strategies in a single-subject perspective to cope with the stressful situations in sports.

Hammond et al. (2013)
The findings suggest that depression among elite athletes is higher than previously reported in the literature.Being ranked among the very elite athletes is related to an increase in susceptibility to depression, particularly in relation to a failed performance.Given these findings, it is important to consider the mental health of athletes and have appropriate support services in place.

Nixdorf et al. (2013)
The findings indicate that we can no longer deny the issue of depressive symptoms among elite athletes.Relevant factors such as chronic stress, coping strategies, and level of exhaustion and recovery may be practical starting points for establishing preventative programs and supportive interventions for depressed athletes.

Didymus & Fletcher (2014)
The results demonstrate the complexity of coping and support the notion that there may not be a 'one size fits all' answer to the question of which coping strategies are most effective in managing organizational stressors.
could follow.Other authors highlight that competitive swimming can lead to mental health problems, associated with other factors such as harassment and abuse, and the need to maintain a slim figure or a low body weight to compete.However, most of the studies agree that competitive swimmers should have a psychological support service and receive psychological preparation in this regard, which would help them as a tool for achieving goals and regulating anxiety in order to achieve a positive motivational climate that would allow them to reach a high degree of mental and physical well-being.

Discussion
This study aimed to carry out an analysis of the scientific tests taken in mental health in the discipline of swimming, as well as to examine the type of instrument used to evaluate and diagnose this situation in highly competitive swimmers.
In competitive swimming, mental health has been assessed from different perspectives and with great scientific heterogeneity.One of the possible causes could be associated with the fact that swimming is related to other areas of knowledge (Navarro et al., 1990), among which is psychology.The range of variables studied in this area has generated some uncertainty and overlooked certain factors that may have influenced swimmers' vulnerability to mental health symptoms and disorders (Bär & Markser, 2013).Likewise, some studies highlight that there are more than 640 different stressors (Arnold & Fletcher, 2012) and that together with the sports withdrawal, they could develop a high probability of suffering from symptoms and mental health disorders (Arnold & Fletcher, 2012;Wylleman & Reints, 2010).Therefore, it may be highlighted that mental health has not been analysed and evaluated in depth and rigour, according to the scientific literature.However, there are also controversies since other authors defend the idea that swimming positively affects general somatic health (Oja et al., 2015;Tanaka, 2009) and mental health (Cordeiro et al., 2017;Yfanti et al., 2014).On the contrary, these opinions differ from those other researchers give when discussing mental health in high-level sports and its stressors and conditioning factors (Henriksen et al., 2020).For this reason, this scientific diversity has generated some uncertainty among researchers, not knowing what to focus their studies on when evaluating and diagnosing due to the dimensional amplitude of variables.
The reviewed scientific literature shows how the concept of mental health could be clearer between the studies, since most of them have analysed different variables separately (Byrne & McLean, 2002;Didymus & Fletcher, 2014;Hammond et al., 2013;Hooper et al., 2022), to later refer to the term mental health in general.Likewise, most of these studies have focused mainly on variables such as: anxiety, coping, goal setting and depression (Abrahamsen et al., 2008;Nixdorf et al., 2013;Salazar et al., 1997;Simões et al., 2012), neglecting other factors (Arnold & Fletcher, 2012), which could also be analysed and give a more complete view in terms of mental health among swimmers.Therefore, it would be necessary to reach a consensus on mental health and work on these symptoms and disorders in an interconnected way with other factors (risk and recovery from injuries, sports performance, depression and anxiety) and relate them to other symptoms, injuries and physical illnesses (Jones & Hanton, 1996).This could further clarify what mental health is and how it could be extrapolated to swimming, since most of the studies analysed in the literature focus on the study of a reduced number of variables or in the analysis of aquatic disciplines displayed by FINA (Jackson et al., 2022).
Likewise, the scientific literature seems to have not found a consensual categorization of the term mental health.Authors such as Rice et al. (2016) related mental health with: anger and aggression, anxiety, eating disorder and image, general prevalence studies, seeking help, sleep, stress and coping, substance use and well-being.In contrast, The very high physical activity level in this competitive context did not result in significantly better levels on all parameters in comparison with their national counterparts (pain perception, social, emotional, and mental health).

Hooper et al. (2022)
Findings urge sports medicine clinicians to implement psychological screening protocols in elite athletes following the cancellation of a major sporting event to attend to symptoms of psychological distress and to direct appropriate psychological intervention.

Jackson et al. (2022)
Competitive swimming may be a promising conservative therapy for mental health management.However, further research is recommended to solidify these findings and establish the long-term effects of this intervention on mental health.

Mountjoy et al. (2022)
Targeted initiatives are required to address the burden of mental health issues and harassment and abuse in sport in the FINA aquatic disciplines.2019) linked it with: high prevalence disorders (e.g., anxiety and mood symptoms) and more complex mental health disorders (e.g., bipolar and eating disorders).However, the International Olympic Committee (IOC) and its mental health working group (MHWG) have proposed a confidential mental health support service "Mentally Fit".This service could help to clarify the term and establish different categories of analysis (pressure management, physical or psychological exhaustion, harmony between sport and life at home, management of life or career changes, stress management, communication improvement, how to deal with injuries, anxiety control, depression, eating disorders, bullying, harassment and abuse, and parenting).Also, this service could explain all the edges that make up mental health for future research, given the lack of consensus among researchers when categorising mental health.Furthermore, even the International Swimming Federation (FINA) does not have a program similar to that of the International Olympic Committee (IOC) and delegates, according to its general medical regulations, to the members of the Olympic movement.It is therefore questionable whether there is any concern on the part of this competent body for its swimmers in the area of mental health according to its current regulations.
It even reinforces the opinion of some researchers on the lack of concern on the part of federations and institutions (Reardon & Factor, 2010), in the face of this situation in high-level swimmers.Therefore, it would be recommended that the International Swimming Federation (FINA) implement a health program that will help both coaches and athletes to improve their knowledge of mental health problems (Mountjoy et al., 2019), extending this to other aquatic disciplines under FINA conditions (Jackson et al., 2022).
Concerning the methodology used to detect mental health problems in swimmers, it has been shown that most crosssectional, longitudinal and comparative studies do not correspond to high-quality research and intervention trials (World Health Organization, 2018).This situation also corroborates the need for more consensus among researchers when it comes to intervening, preventing and establishing action protocols, to which is added the scarcity of scientific literature (Trinidad et al., 2021;World Health Organization, 2018), being necessary the expansion in this field through specific studies.Furthermore, it would be necessary to increase the analysis sample for future comparative studies (Hainline & Reardon, 2019;Hammond et al., 2013;Purcell et al., 2019), since it was found that most research was at most 15 sample swimmers (Henriksen et al., 2020;Jackson et al., 2022;Oja et al., 2015;Tanaka, 2009).
Regarding the revised instruments for the measurement and diagnosis of mental health in swimmers, there is great heterogeneity since most of them have used between three and four measurement tools.First, for anxiety the following were mainly used: the modified CSAI-2 (Ning et al., 2022;Martens et al., 1990), the direction scale, the mental readiness form (MRF-3) (Krane, 1994) and different self-report scales (Hooper et al., 2022).Regarding coping, the following were used: the career information questionnaire, modified COPE (Carver et al., 1989) and MCOPE (Crocker & Graham, 1995), the performance strategies test (TOPS) (Hardy et al., 2010) and the semi-structured follow-up telehealth interviews (Ning et al., 2022).In order to establish goals, the following were used: the scale of expectations of achieving objectives, the mental training program (MTP) and the perception of success questionnaire (POSQ) (Roberts et al., 1998).
Finally, for depression, the following were used: the semi-structured interview based on the DSM-IV-TR criteria, the BDI-II self-report instrument (Beck & Steer, 1993), center for Epidemiological Studies Depression Scale revised (CESD-R-10) (Jackson et al., 2022) and an online survey.This diversity of resources demonstrates, once again, the lack of consensus and the need to establish a more homogeneous protocol among researchers, in order to know what tools should be used in each aspect of mental health.Therefore, it would be necessary to lay the foundations to reach viable conclusions that can be extrapolated to swimmers to measure and diagnose mental health.All this evidence makes it necessary to carry out specific studies with swimmers and ex-swimmers, in order to carry out intervention protocols and prevention of mental health, rather than waiting for symptoms to appear during sports life or even waiting for the testimonies of retired swimmers.
In conclusion, mental health problems are a salient topic in sports since 1990s.Studies that have analysed mental health symptoms and disorders in competitive swimmers have been insufficient in the scientific literature.They have even valued it from different dimensions and tools, masking the problem or simply reporting data that have not helped to clarify what mental health is.Therefore, it is necessary to fill this gap with studies that work under the same consensus and in collaboration with specified technical teams, in order to supervise, evaluate and provide services, through detection tests and support to swimmers in their training, as well as before and after competitions.Moreover, there should be a direct involvement by the competent bodies and institutions to tackle, instead of ignoring or mismanaging this situation, in order to respond to the needs of swimmers.Finally, mental health is everyone's responsibility, from the swimmer himself to the bodies and institutions involved, and interdisciplinary and collaborative work should be done, establishing specific programs based on the sport in order to guarantee efficient prevention and care.quantitative analysis of scientific publications in order to identify and evaluate research trends and patterns within the field of mental health in sport in general.In our case, we focused our analysis on swimming and specifically on the instruments used and variables analysed within the scientific literature.Why do you indicate that it is a narrative review, if in Figure 1.you include a flow chart?Key aspect of a systematic review.

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Dear reviewer, in response to your question, it has been decided to add a flowchart to the narrative review (Fig. 1) in order to give more emphasis and consistency to the research by graphically showing the steps or processes to be followed to reach the solution of the study problem.

Version 1
Reviewer Report 16 November 2023 https://doi.org/10.5256/f1000research.153869.r213018 © 2023 Ruano M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Miguel Ángel Gómez Ruano
1 Universidad Politécnica de Madrid, Madrid, Spain 2 Universidad Politécnica de Madrid, Madrid, Spain The narrative review submitted is quite interesting, well-prepared, and useful for coaches and researchers interested in improving the mental health of their swimmers.I have some comments and suggestions in order to improve the meaning and readability of the manuscript.
Please use the impersonal form when writing through the manuscript.Table 1 should be presented by pooling the studies that used the same methodology, then this would clarify the visual inspection of every study.

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The discussion could be enriched using an infographic that summarizes the main factors and variables under analysis.

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The type of review used in the methodology was described.For this, the suggested reference was taken into account.Subsequently, the References section was updated.
A narrative review or literature review was carried out where the materials published in the literature (tests and instruments to evaluate and diagnose mental health in highly competitive swimmers) were described, in order to perform a textual, tabular or graphic synthesis of Your results.and contributions (Grant & Booth, 2009).Method, please add the date when the search was made.

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Corrected.Thanks for the comment.
The start of the study was in February 2023 through combined search processes, in which potential studies, clearly planned and ordered, were identified.In orden to perform that, the following bibliographical databases were consulted: Dialnet, WOS (Web of Science) and Scopus with the following search terms included in Boolean search strategies:

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Corrected.Thanks for the comment.Table 1 should be presented by pooling the studies that used the same methodology, then this would clarify the visual inspection of every study.

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Corrected.Thanks for the comment.The discussion could be enriched using an infographic that summarizes the main factors and variables under analysis.

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Thanks for the suggestion.I will ask the magazine if this option is possible within the discussion section.
The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com climate, performance and specialty-performance Somatic anxiety, worry and concentration disorder Torstveit et al. (2008) Eating disorders Romberg et al. (2012) Psychosomatic index, life-esteem and self-esteem Simões et al.Abuse in their sports environment Ning et al. (2022) Mindfulness level Flow state Anxiety, depression, training, and competition satisfaction

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Figure1, should consider only 3 phases according to PRISMA 2020 guidelines, please modify it accordingly.

Table 1 .
Methodologies, samples and swimming categories analysed and their relationship with mental health in competitive swimmers.

Identification of studies via databases and registers Identification Screening Included Figure
1. Identified articles flow chart.

Table 3 .
Main instruments for analyzing mental health symptoms and disorders in competitive swimmers.

Table 4 .
Main contributions of the studies analysed.

Table 4 .
Continued Ning et al. (2022)The MAIC mindfulness training program based on localization design has an obvious improvement effect on college "swimmers" mindfulness level, flow state, anxiety, depression, and training competition satisfaction, with a good continuity effect.

the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests:
No competing interests were disclosed. ○Is

Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Are all the source data underlying the results available to ensure full reproducibility? No source data required Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Sport Sciences I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. impersonal
. Apologies for this.Introduction, first paragraph, line 3, please write (WHO) after World Health Organization.Moreover, the World Health Organization (WHO) defines "global health" as "a state of complete physical, mental, and social well-being,".Methods, authors should describe what type of review they are conducting, in this case, a narrative review.I suggest using the following reference to justify the methodology used: Grant, M. J., & Booth, A. (2009).A typology of reviews: an analysis of 14 review types and associated methodologies.Health Information and Libraries Journal, 26, 91-108 1 .
○Corrected.Thanks for the comment.